Subscribe To

Sunday, January 29, 2017

This
article in the Journal of the American Board of Family Medicine
begins, “Clinical practice guidelines abound. The recommendations contained in
these guidelines are used not only to make decisions about the care of
individual patients but also as practice standards to rate physician
‘quality.’” Did you know that? I have for awhile, and it concerns me. I first
became aware of it during the funding cuts in Medicare (+/- $750 billion) during the “negotiations”
leading up to the passage of the “Affordable Care Act” (ACA, aka Obamacare).

The Journal article continues,
“Thus there is an inevitable aspect of guideline development that makes it
subject to value judgments and can be unconsciously colored by intellectual,
professional, or financial conflicts of interest.” These include biases such as
“decisions colored by tunnel vision (job conditioning), ‘seeing what you want
to see’ (confirmation bias), decisions limited to the tools at hand (Maslow’s
hammer), or other inclinations that can affect judgment.” That last one especially
concerns me. Why? Medicare Payment Reform.

We have all become aware of the
movement towards Electronic Health Records (EHR). But did you know that there
are financial incentives and
disincentives for physician compliance? The EHR program, called Meaningful
Use (MU), is now in the process of being itself re-reformed. According to a blog post from Impact Advisors, posted before
the final rule was issued, “providers simply wanted to ‘check the box’ in order
to reach MU thresholds (and thus avoid ‘adjustments,’ i.e., penalties),
foregoing the larger opportunity to improve care.”

EHR was Part 1 of a larger reform
program of the Center for Medicare and Medicaid Services (CMS). It is still in
place, but Part 2, described as “share data” and Part 3, “improve outcomes,”
are now part of a new Medicare
Payment program designed to overcome the “noted weaknesses of MU.” Part 1 will
be transformed and phased in by stages starting in 2017. Parts 2 and 3, now the
Merit-Based Incentive Payment System (MIPS), is part of the Medicare Access and
CHIP Reauthorization Act (MACRA) and implementation begins in 2019.

Now, according to an AMA email “alert”
that I received last fall, CMS has issued its final MACRA rule, detailing the
new Merit-Based Incentive Payment System, now called the Quality Payment
Program (QPP). In the email, AMA President Andrew Gurman thanked CMS Acting
Administrator Andrew Slavitt for being a “sincere partner” during the process.
Gurman was very pleased at the influence the AMA’s comments had that “will
allow for a reasonably paced progression into the program so that physician
practices can learn and adjust…”

He said, “The
key elements of the proposed rule that CMS changed based on our recommendations
are:”

●Physicians
would not have to report in all four MIPS categories to avoid anegativepayment adjustment.
Instead, the only physicians who “will experience a negative 4% penalty in 2019 [increasing in steps to 9% by 2022]
will be those who choose to report no data.”

●Participating
in one of 4 options under “Pick Your Pace” will “help the physician avoid penalties.” At the very least if
(s)he “chooses to report for only one patient on just one quality measure, one
improvement activity, or the 4 required Advancing Care information (ACI)
measures, [(s)he] will avoid a negativepayment adjustment.”

●The
final rule established a 90-day reporting period, “a significant change over
the proposed rule, full calendar-year requirement.” If the physician reports
for at least 90 continuous days in 2017, (s)he will be eligible for a positive payment adjustment. This
adjustment allows the physician to start later, to have more time to prepare.

●A
reduction in the program-wide reporting burden from 11 reporting measures to 4
in 2017 and 5 thereafter.

●“An increase in the low-volume
threshold to qualify for exemption
from QPP participation.” CMS increased the threshold from $10k to $30k in
Medicare payments, but kept the 100
Medicare patients per year limitation. So, know that your physician has
been incentivized to not accept new
Medicare patients, and to drop the
old ones.

Does this give you a
sense of why your relationship with your doctor has changed in recent years? I
started this column feeling a bit angry at my doctor. I end it feeling sorry
for him. Look what’s happening to Medicare!

Sunday, January 22, 2017

This title is in
quotes because…I think I cribbed it from Kelley Pounds, an RN, CDE, blogger and
diabetes educator whose writings I always find interesting and informative.
But, alas, I can’t link to it here because I can’t find that title in her Table
of Contents. So, a hat tip to Kelley Pounds and this link
to her home page.

The point of the
title is that Kelley, and I and many other “activists,” and of late, some researchers,
are urging the public health establishment in the U. S. and world-wide to take
a hard look at the current Standard of Practice for defining Prediabetes and
consider lowering or re-defining it. The implications of doing this are
momentous; but likewise, if this is not done, the outcomes will becatastrophic. Consider this recent revelation from the CDC: “Life
expectancy for the U. S. population in 2015 was 78.8 years, a decrease of 0.1 years from 2014.”
That’s the first DECREASE IN LIFE EXPECTANCY in the U.S. since 1999. Think it’s
related to our lifestyle?

A ton of
evidence associates LIFESTYLE DISEASES
with METABOLIC SYNDROME, the major
outcomes of which are Type 2 Diabetes and heart disease. That’s why BETTER STANDARDS are needed to address
this scourge.

THE LIFESTYLE DISEASES

Cardiovascular
Disease (CVD), Coronary Heart Disease (CHD), Stroke, Type 2 Diabetes Mellitus
(T2DM), Non-alcoholic Fatty Liver Disease (NAFLD), Alzheimer’s Disease, aka
Type 3 Diabetes, and even Erectile Dysfunction. Also several types of cancer; A large population study, in “Diabetes Care,”
shows that “the
relative risks of
various cancers imparted by diabetes
are greatest (about twofold or higher) for cancers of the liver, pancreas, and
endometrium, and lesser (about 1.2–1.5 fold) for cancers of the colon and
rectum, breast, and bladder.”

METABOLIC SYNDROME

A WebMD stub puts it succinctly: “Metabolic
syndrome is a collection of symptoms that can lead to diabetes and heart
disease. The good news is that metabolic syndrome can be
controlled, largely with changes to
your lifestyle.” The five related symptoms, first introduced six years
ago to my readers here, and updatedhere, and then here
and here, are: a Body Mass Index
(BMI) ≥30, or large waist circumference (men ≥40 inches, women ≥35 inches);
elevated triglycerides (≥150mg/dl), reduced HDL, the “good” cholesterol (men
≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg, and/or use of medications for
hypertension) and elevated fasting glucose (≥100 mg/dl, and/or the use of medications for hyperglycemia).

THE BETTER STANDARDS

In the U.S. the
longstanding criteria for a clinical diagnosis of Type 2 Diabetes Mellitus
(T2DM) was two consecutive office visits with a fasting blood sugar ≥140mg/dl
(7.8mmol/L). In 1997 that standard was lowered to ≥126mg/dl (7.0mmol/L). In
2002 a definition for Pre-Diabetes was added: an IFG ≥ 100 to 125mg/dl (5.6 to
6.9mmol/L) or an IGT of 140 to 199mg/dl (7.8 to 11.0 mmol/L) two hours after a
75 gram glucose challenge. The WHO uses a higher IFG threshold: ≥110to 125mg/dl
(6.1 to 6.9mmol/L). Later, in the U. S., the HbA1c measurement was added to
supplement or in some cases now to supplant the IFG. In the U. S., an HbA1c
between 5.7% and 6.4% is considered Pre-Diabetic and ≥6.5% Type 2 Diabetes.
Elsewhere in the world, Pre-Diabetes is defined as an “A1c” ratio between 49
and 56mmol/mol and Type 2 Diabetes as ≥58mmol/mol.

For years
leading research scientists like Ralph A. DeFronzo and pioneering clinicians like Richard K. Bernstein have called for a lower
standard for the diagnosis of incipient Type 2 Diabetes. These men are leading
diabetes specialists who have devoted their lives to combating this disease.
They are both superstars.

Now, as I
reported in #362, the BMJ (British Medical Journal) has just published a
Chinese meta-analysis done on 1,611,339 people. The lead
researcher’s takeaway: “Effective intervention in prediabetes is not just
for prevention of diabetes, but also cardiovascular diseases.” The
majordomos are starting to connect the dots.

WHAT HAS TO BE DONE?

Type 2 Diabetes has
to be redefined, as DeFronzo and Bernstein would say – indeed have said: “Prediabetes, in other words, is Type 2
Diabetes.”

And at the clinical
level today, physicians, using the current standard, have to not
treat Prediabetes with temporizing measures, e.g., “We’ll have to monitor your
blood sugar” (read: to watch your Insulin Resistance worsen as you eat the Standard American Diet. Clinicians need to tell you:
“You are Carbohydrate Intolerant.”

Sunday, January 15, 2017

Okay, so which is it? A Dietary
Disease or a Lifestyle Disease? It’s both, of course; diet is a part of Lifestyle. But why then is
Establishment Medicine comfortable with calling it a Lifestyle Disease and not a Dietary Disease? They would tell
you that lifestyle includes such things as doing 175 minutes of exercise a week
(which while good, isn’t necessary) and giving up smoking (which while also
good, isn’t relevant to diabetes). Forget the epidemiological studies that show
an association with Type 2 Diabetes.
That’s demographic, not causal.

Exercise is a great habit to have.
It builds muscle, keeps you fit, and if you’re a Type 2 or even Prediabetic, it
improves your insulin sensitivity. But
it’s not necessary. Eating fewer carbs, thereby secreting less
insulin, also improves your insulin
sensitivity. “Insulin causes Insulin Resistance,” as Dr. Jason
Fung recently blogged.

No, Establishment Medicine probably
doesn’t want to call Type 2 a Dietary Disease for a number of reasons:

1)
Some clinicians simply don’t know. I know that’s hard to believe, but
I’m afraid it’s true. It’s called “tunnel vision.” See #365, to be posted in
two weeks, “The Dual Pincers of Clinical Practice Guidelines.”

2)
If you understood that Type 2 Diabetes and Prediabetes are Dietary Diseases, then the “treatment” would be
a changed diet, not pills and injections… and
you could still advocate for exercise and secession of smoking. Ah, but then it
would be a less persuasive and perhaps a less effective argument if it was not linked tothe avoidance of Type 2 Diabetes.
And, if you didn’t have a prescription to write, the patient would feel
“cheated.” The patient wants you,
oh omnipotent dispenser of scripts, to “cure” this pernicious disease forthem.

3)
If Type 2 Diabetes and Prediabetes are acknowledged to be Dietary
Diseases, caused by the dietary advice that Government Dictocrats have mandated
and Medical Establishment has peddled for the last 55 years, then your
doctor, if he or she were to tell you to change your diet to almostthe
exact polar opposite of what he or she has been telling you to eat over
these many years, they would look pretty silly or just stupid. And the general
public, and your doc’s patients in particular, would lose confidence in these
omniscient demigods.

4)
The ADA used to say that low carb diets were not safe. Then, the
evidence from controlled trials proved them wrong. Then they said they were
safe for a limited time only; then the evidence proved that wrong too. Then
they said – actually, they’ve said all along – that low carb diets were too
difficult to follow. That’s true for some, but certainlynot truefor many others. Others found them easier to follow than a low-fat, calorie- restricted, “balanced”
diet because weight loss without
hunger was possible. And followers of low-carb, high- fat diets,
besides keeping the weight off, hadbetter glucose control and better lipid
(cholesterol) profiles!

No, it’s easier to see the patient,
take a blood sample, and then tell them (in a phone call or a note with your
lab test) that, “Your sugar is a little high; we’ll have to monitor that.” And
when you continue to eat the same prescribed “balanced” diet, and exercise as
you were told, and your blood sugar goes higher still, the doctor will tell
you, as Tom Hanks related to David Letterman, “You’ve
graduated; you’re now a Type 2 Diabetic.”

Well, what did you
expect? You continued to do the same
thing and yet you expected a
different result? Type 2 Diabetes is a Progressive Disease. Insulin
Resistance is a Progressive Condition. Insulin Resistance = Type 2 Diabetes.
Insulin Resistance = Carbohydrate Intolerance. The only effective treatment
for a Dietary Disease isa different diet. The only
effective treatment of Type 2 Diabetes is a Low Carbohydrate Diet. Not
“watching your blood sugar” as it progressively worsens. Not treating this symptom
– an elevated blood sugar – with a drug that will force your pancreas to secrete
more insulin and thus eventually wear out and destroy it. Type 1 Diabetes is a disease of too little insulin. Type
2 Diabetes is a disease of too
much insulin. The best way to treat your pancreas, and
thus save it, is give it a break! Eat a low carb diet!

Sunday, January 8, 2017

A recent Reuters Health Information article in Medscape
Medical News headlined, “Meta-Analysis Backs Stricter Prediabetes Definition.”
It reports on a new study in the BMJ (British Medical Journal)
that “people with a fasting glucose as low as 100mg/dl (5.6mmol/L) are at
increased risk of cardiovascular disease.” It also showed increased CVD risk in
individuals with an HbA1c as low as 5.7% (39 mmol/mol). What is significant
about this Chinese study is that it is very
large (53 studies, comprising 1,611,339 people). The big takeaway: “Effective intervention in prediabetes is
not just for prevention of diabetes, but also cardiovascular diseases.”

This isn’t news to my regular readers. I have been saying it
forever, most recently in the risk analysis presented in #345, “How Diabetic Do You Want to Be? (Part 2). That
column was based on the laudatory work of Jenny Ruhl at her website,
Blood Sugar 101. Jenny has meticulously collected and provided links
to the best research. Her books, “Blood Sugar 101” and “Diet 101,” are awesome
too.

Based on the ADA criteria for an Impaired Fasting Glucose
(IFG) of 100mg/dl to 125mg/dl (5.6 to 6.9mmol/L), the study found that the
association between prediabetes and various co-morbidities is as follows: CVD ↑
13%; CHD ↑ 10%; Stroke ↑ 6% and All-Cause Mortality ↑ 13%. But the ADA criteria
is “contentious,” the authors told Medscape, and “has not been used in other
international diabetes management guidelines.” The WHO (World Health
Organization), for example, uses a higher cutoff for diagnosing an IFG, 6.1 to
6.9mmol/L (110-125mg/dl), and thus has a higher hazard ratio for “composite
cardiovascular disease” of ↑26%.

Similarly, the ADA’s prediabetes criteria for an HbA1c is
39-47mmol/mol (5.7% -- 6.4%), whereas the National Institute for Health and
Care Excellence (NICE at NHS) cutoff, 42-47mmol/mol (6.0% -- 6.4%), is
different. As a result, CVD relative risks vary from 13% (IFG-ADA) to 26%
(IFG-WHO), relative risks for CHD vary from 10% to 18%, and relative risks for
stroke vary from 6% to 17%. The authors also argue for the standardization of IFG and IGT (Impaired Glucose Tolerance), and
the worldwide incorporation of HbA1c
in defining prediabetes.

But let’s not get lost
in the weeds. The bottom line is this: The
current cutoffs worldwide for a diagnosis of prediabetes are strongly associated with an increased risk
of CVD, CHD, stroke and all-cause mortality. This is in addition to
the usual microvascularcomplications of T2DMof nephropathy (end-stage kidney
disease), retinopathy (blindness), and neuropathy (leading to amputations).
There is also a similar pattern for dementia.

That’s the message, and that is why I am pleased to see this
hue and cry for a stricter and more standardizedprediabetes definition. The medical doctor’s response was
predictable: “People with diabetes
should be followed up and should maintain a healthy lifestyle” (emphasis added
by me). And “many drugs prescribed for diabetes may be useful in people with
prediabetes (metformin, acarbose).” The latter is also not news, but it is
surprising how many doctors don’t know this and do not routinely employ this
intervention in clinical practice.

Then, according to Medscape, the study’s lead author, obviously
a research physician, suggests that, “First, we need to develop models for risk
stratification in people with prediabetes. Second, we will select higher-risk
people with prediabetes to evaluate whether drug treatment can prevent
cardiovascular disease in them.”

Sunday, January 1, 2017

As I write this in mid
December, I have just learned that two people that I thought I was helping are
paying no attention. This news is worse than discouraging. It’s depressing –
but not so much for me. I’m trying not to think of myself. I don’t write this
stuff for myself. Okay, I do, a little, but I do it primarily for my friends,
my faithful readers, and people who stumble on a column through Google. But it’s
especially disheartening to learn that people whose health should be of
paramount concern to them…areignoringtheir health and my advice.

Okay, I’m not a health professional, and I’m certainly not a
doctor. I don’t have the opportunity to order blood tests and deliver the bad
news to the patient. And then, when they are most vulnerable, tell them to take
a pill or even to follow a certain way of eating. But I can’t for the life of me (LOL) figure out why anyone would listen to a doctor in the
matter of what to eat. I mean, what in bloody hell do they know about “healthy eating.”

Oh, I forgot. Government Dictocrats have been telling us what
to eat to prevent heart disease since
at least 1977, and updating their advice every 5 years. In fact,
it began after President Eisenhower’s first
heart attack in 1955. By January 1961, Ancel Keyes had made it onto the cover
of Time magazine, and the basic
advice then and now is to avoid
saturated fat and cholesterol, to eat mostly a plant-based diet primarily with
fats from corn and soy bean oil. A diet, per the Nutrition
Facts Label on processed food, of 60% (300g) carbs, 10% (50g) protein and
30% (67g) of the aforementioned oxidized polyunsaturated vegetable and seed
oils (PUFAs) manufactured by the industrial food giant conglomerates supported
by the USDA.

Now it’s true that in recent years the USDA/HHS/FDA have
backed off a little. They no longer limit total fat to 30%, but they insist
that to the extent that percentage is increased, you do it with those PUFAs,
not the saturated fats from animals. And it’s true that the Dietary Guidelines
Advisory Committee told the full panel on December
14, 2014, that “Cholesterol is no longer a nutrient of concern for
overconsumption,” but after the full panel held Congressional hearings, the
final 2015 Guidelines totally water down that recommendation.

There are also lots of news articles appearing now about the
benefits of full fat dairy products like milk and yoghurt. But guess what? Have
you tried to find full-fat yoghurt in the grocery store recently? Good luck!
But what do you expect? Do you think the Government is going to tell you their
advice for the last 55 years has been all
wrong? Of course not. It’s unthinkable. So, you have to decide for yourself
what healthy eating is.

I could even cite several scientific reviews questioning –
neigh, disparaging the advice to reduce the intake of salt. I’ve cited them
over and over here,
here,
and here.
But, does anyone listen to me? No. Poor, poor me.

Recently I learned that one friend who needed to lose weight
that he had gained because of medications he must take – was successful in
following a low-carb regimen I had advocated. Then, with his wife, he switched
to Weight Watchers. Maybe he did it to support his wife’s efforts. Maybe it’s
easier. I hope he’s successful.

Then another friend, who also has medical issues, had on the
advice of her physician gone
vegetarian. And guess what? She’s tired all the time, and blood tests her
doctor ordered showed her to be protein deficient. Quelle surprise! She and her
husband, who is in worse shape than she, both have ignored my advice for years.

Okay, I am feeling sorry for myself. But I am also worried for
them, and for you too – for their
health and yours. Don’t they realize
that is all they have that is important (besides each other)? Don’t you realize it?

I just learned a few days ago that another friend died
suddenly about a month ago. Maybe this rant is because I’m grieving for him too
and for all my other friends and everyone else who is whistling past the graveyard. Thinking about myself, I originally
thought of naming this column, “Whistlin’ Dixie,” but that would have made this
column about me. This is really about you, my friends: It is you
who are
whistling past the graveyard.

January 1st
is the scheduled publication date for this column. It will also be the 1st day of the rest of your life.

About Me

I was diagnosed a Type 2 diabetic in 1986. I started a Very Low Carb diet (Atkins Induction) in 2002 to lose weight. I didn’t realize at the time that it would put my diabetes in clinical remission, or that I would be able to give up almost all of my oral diabetes meds. I also didn’t understand that, as I lost weight and continued to eat Very Low Carb, my blood lipids would dramatically improve (doubling my HDL and cutting my triglycerides by 2/3rds) and that my blood pressure would drop from 130/90 to 110/70 on the same meds.
Over the years I changed from Atkins to the Bernstein Diet (designed for diabetics) and, altogether lost 170 pounds. I later regained some and then lost some. As long as I eat Very Low Carb, I am not hungry and I have lots of energy. And I no longer have any of the indications of Metabolic Syndrome.
My goal, as long as I have excess body fat, is to remain continuously in a ketogenic state, both for blood glucose regulation and continued weight loss. I expect that this regimen will continue to provide the benefits of reduced systemic inflammation, improved blood lipids and lower blood pressure as well.